1965-1990: 25th anniversary of nurse practitioners. A classic manuscript reprinted in celebration of 25 years of progress. The Burlington randomized trial of the nurse practitioner. 1971-2.

From July 1971, to July 1972, in a large suburban Ontario practice of two family physicians, a randomized controlled trial was conducted to assess the effects of substituting nurse practitioners for physicians in primary-care practice. Before and after the trial, the health status of patients who received conventional care from family physicians was compared with the status of those who received care mainly from nurse practitioners. Both groups of patients had a similar mortality experience, and no differences were found in in physical functional capacity, social function or emotional function. The quality of care rendered to the two groups seemed similar, as assessed by a quantitative "indicator-condition" approach. Satisfaction was high among both patients and professional personnel. Although cost effective from society's point of view, the new method of primary care was not financially profitable to doctors because of current restrictions on reimbursement for the nurse-practitioner services.

The impact of continuing education on the quality of patient care.

We randomly allocated family physicians meeting explicit entry criteria to experimental and control groups to determine whether CME affects the quality of patient care. The experimental group received educational packages, the control group did not. These educational packages were closely matched with explicit criteria used in the indicator condition-our method of measuring the quality of care. The indicator conditions were divided into elective, mandatory and hidden categories. We compared over 4,500 patient encounters, before and after the educational maneuver, with explicit clinical criteria in the indicator condition. These episodes of care were then classified according to quality of care. Though knowledge increased from the educational packages, overall quality of care improved very little. If the topics were elective, quality of care improved equally in both the experimental and control groups. When the topics were mandatory, quality of care provided by the experimental group improved (P < 0.05). Topics covered by the hidden indicator conditions showed no spillover effect.

A randomized trial of continuing medical education.

To determine whether continuing medical education affects the quality of clinical care, we randomly allocated 16 Ontario family physicians to receive or not receive continuing-education packages covering clinical problems commonly confronted in general practice. Over 4500 episodes of care, provided before and after study physicians received continuing education, were compared with preset clinical criteria and classified according to quality. Although objective tests confirmed that the study physicians learned from the packages, there was little effect on the overall quality of care. When the topics were of relatively great interest to the physicians, the control group (who did not receive the packages) showed as much improvement as did the study group. When the topics were not preferred, however, the documented quality of care provided by study physicians rose (P less than 0.05) and differed from that provided by control physicians (P = 0.01). Finally, there was no spillover effect on clinical problems not directly covered by the program. In view of the trend toward mandatory continuing education and the resources expended, it is time to reconsider whether it works.

Research methods workshop for health professionals in Sierra Leone: an international collaborative project.

In 1979 a research methods seminar for health professionals in Sierra Leone was conducted as part of an international medical education collaborative project between Sierra Leone, Canada, the United Kingdom and the European Economic Community. The aim of the seminar was to promote research and inquiry into national health problems. Planning and administration was conducted by Sierra Leone with Canada providing teaching materials and four tutors. Twenty-seven participants attended the seminar. Participants prepared research protocols prior to the seminar which they developed and refined during the 7 days of the workshop. Using a problem-based method Sierra Leonean health problems were used as the focus to teach epidemiological and biostatistical methods. The seminar was evaluated on the basis of a number of parameters. There was 89% attendance at the nineteen sessions. Twenty-one of the twenty-seven participants presented protocols at the final evaluation session. Self-evaluation of protocols showed improvement in most aspects but particularly in research design, methods of data gathering, analysis and ethical aspects. An opinion survey of participants showed the seminar to be viewed positively. Twelve months later six participants had submitted their protocols for funding of whom four were successful. A further seminar has been conducted in which Sierra Leoneans participated as co-tutors. This seminar format has been presented as an effective means of providing professional assistance from one country to another.

Quality-of-care appraisal in primary care: a quantitative method.

A reproduceable method has been developed for measuring the quality of clinical care provided by physicians and nurse practitioners. The distinctive features of the method are the extended use of the tracer disease concepts, the evaluation of referrals, new procedures for probing the clinical operation of practices, a single blind design, emphasis on the use of the untouched medical record, the ability to compare results with measurements of concurrent outcome, and a relatively low cost. Three simultaneous approaches used in the method are described: surveillance of the management of indicator conditions, evaluation of clinical use drugs, and the assessment of referral decisions. The three approaches gave consistently similar results about the relative performances of the practices compared and were in agreement with concurrent outcome studies. The method was successfully implemented in a health care experiment.